Abstract

Background A pilot study was conducted to determine whether the caregivers of children being seen at the Ochsner for Children health center were eligible for and using services provided by the Smoking Cessation Trust (SCT).

Methods The study population consisted of pediatric patients' caregivers who visit the Ochsner for Children health center. Caregivers were offered a questionnaire to assess their age, sex, relationship to the child, medical insurance, smoking status, and prior cessation attempts and aids. Data about 3 other caregivers were also requested from the visiting caregiver.

Results Of the 84 caregivers assessed, 26 (30.95%) smoked, of whom 12 (46.15%) began smoking prior to 1988 and were eligible for SCT services. The cohort of eligible caregivers included 4 grandmothers (33.33%), 2 grandfathers (16.67%), and 3 fathers (25.00%). Smoking prevalence in our cohort was higher than the national average (31% vs 18%). During the previous 12 months, 3 of 12 (25.00%) SCT-eligible caregivers had tried to quit smoking. Four (33.33%) SCT-eligible caregivers were interested in smoking cessation.

Conclusion Pediatricians are in a unique position to screen, counsel, and refer caregivers who smoke to the SCT.

INTRODUCTION

Smoking is the single most preventable cause of morbidity and mortality in the United States.1 The Centers for Disease Control and Prevention (CDC) estimated that 46.6 million people smoked in 2010.1 Although this number represents only 18% of the 2015 population according to the CDC,2 approximately 54% of children aged 3-11 years are exposed to secondhand smoke.1 Levels of cotinine, a major metabolite of nicotine, can be up to 7 times greater in children of parents who smoke compared to children of nonsmoking parents.3 Secondhand smoke is responsible for up to 300,000 annual cases of bronchitis, pneumonia, and otitis media in infants and children1 and is estimated to cause >5,000 deaths annually.4 These data demonstrate the need for smoking cessation for the benefit of both caregiver and child.

Smokers who participate in cessation programs are more likely to reach their goals.5 In Louisiana, the Smoking Cessation Trust (SCT) is available to help residents who began smoking prior to 1988. The SCT is the result of a 14-year class action lawsuit, Scott vs American Tobacco Company, and the ruling in 2011 awarded eligible Louisiana residents a supervised smoking cessation program and access to smoking cessation services at no cost.6 Residents eligible for SCT services represent approximately 200,000 smokers in Louisiana.6 However, only 30,731 eligible smokers applied for SCT-funded smoking cessation services in 2013.1,6

The American Academy of Pediatrics recommends that all pediatric healthcare providers ask caregivers if they smoke, advise smokers of the health effects of secondhand smoke, and refer caregivers who smoke to available cessation services.7 No data exist regarding whether smokers in Louisiana who care for pediatric patients are using SCT services.

METHODS

The primary objective of this cross-sectional study was to determine the ages of caregivers of our pediatric patients to assess their eligibility for participation in SCT services. A secondary objective was to obtain information on caregivers' sex, relationship to the child, medical insurance status, prior smoking cessation attempts, prior use of smoking cessation aids, and current smoking cessation interest to better understand the demographics of this population. The study population consisted of caregivers of pediatric patients who visited the Ochsner for Children health center from September 1, 2014 to January 1, 2015. The inclusion criteria were that the respondent be a caregiver and be able to provide information about other caregivers of the child.

A licensed practical nurse gave caregivers a questionnaire to complete. The questionnaire was self-administered and consisted of 34 questions that investigated the smoking status and demographic features of the patients' caregivers. The caregivers were informed that the questionnaire would take approximately 5 minutes to complete and that participation in this study was voluntary. The caregivers were also instructed that the completion or noncompletion of the questionnaire would not affect the treatment the patient received.

This study was reviewed by the Ochsner Institutional Review Board and met the criteria for exempt research.

A descriptive analysis was conducted to identify the average age of caregivers, the distribution of caregiver relationships and medical insurance status, and the proportion of caregivers who smoked. A subset analysis was conducted within the group of caregivers who smoked to determine the percentage of SCT-eligible caregivers and their attitudes about and actions toward smoking cessation.

RESULTS

Twenty-nine participants completed the questionnaire, and each participant gave information on up to 3 additional caregivers, resulting in a total of 84 assessments. Twenty-six (30.95%) caregivers smoked, of whom 12 (46.15%) began smoking before 1988 and were eligible for SCT services. Four (33.33%) SCT-eligible caregivers were interested in smoking cessation. Figure 1 represents the SCT eligibility of the caregivers and those interested in smoking cessation.

Of the 12 SCT-eligible caregivers, 3 (25.00%) reported that they had tried to stop smoking during the previous 12 months. Of the 3 eligible caregivers who had tried to quit smoking, 2 (66.67%) used bupropion or varenicline, 1 (33.33%) used nicotine replacement medication (ie, patch, gum, lozenges, spray), and no caregivers used programs offered by the SCT.

DISCUSSION

This study reveals that many SCT-eligible caregivers are not benefiting from the smoking cessation services offered by the SCT. Thirty-one percent of the caregivers in our cohort smoked, almost double the national average of 18%.2 These results suggest that Louisiana residents in general, and pediatric patients specifically, are at an increased risk of smoking-related morbidity.

Of the caregivers who smoked, 46% were eligible for the SCT, and one-third of SCT-eligible caregivers indicated that they were interested in quitting. Furthermore, 25% of eligible caregivers had tried to stop smoking in the previous 12 months. Given that the pediatricians at Ochsner have access to approximately 8,729 SCT-eligible smokers per year, our results suggest that 2,881 caregivers may be motivated to quit smoking using SCT services. Pediatricians should use the opportunity to refer eligible caregivers to the SCT.

In 2013, only 30,731 of the estimated 200,000 eligible smokers in Louisiana were enrolled in the SCT.6 This enrollment represents only 15.4% of all eligible smokers in the state, much lower than the 33% of eligible smokers in our study who indicated that they were interested in quitting. In addition, none of our subjects reported using SCT services to aid their smoking cessation attempts. These statistics shed light on a pressing issue facing Louisiana today. In a state with a high prevalence of smokers, only approximately 15% of eligible residents are using SCT services.

The question that begs to be answered is this: why are more people not using SCT services? One reason may be the trust's inability, because of the nature of the SCT agreement, to directly advertise its services. Consequently, primary care physicians are in a position to play an important role in disseminating information about and promoting the SCT. Another reason may be that limited financial and social resources prevent some patients from seeking smoking cessation guidance from their primary care physician. Pediatricians and other healthcare providers can help ensure that caregivers who smoke are aware of the available smoking cessation services. However, many physicians are not aware of smoking cessation programs and are not promoting them to patients, so physicians should familiarize themselves with the available programs.8

Widely promoted smoking cessation programs make it easier for smokers to quit.9 The State of Massachusetts' experience with a widely promoted Medicare smoking cessation program provides a good example of the importance of promoting programs such as the SCT. In a study by Land et al, a smoking cessation program was heavily promoted to Medicare recipients, resulting in 37% of Medicare enrollees using the program.10 Smoking rates fell from 38% to 28%, while myocardial infarctions dropped by half. For every $1.00 Medicare spent on the smoking cessation program, $3.12 was saved among Medicare enrollees.10,11

Smoking cessation services are not equal. Medicare programs, for example, have copay requirements and variable coverage depending on the individual's plan.11 Removing such barriers is essential to increase smoking cessation rates.10,12 In contrast to Medicare, the SCT does not impose such restrictions. The SCT provides, at no cost to the patient, cessation medications, individual/group cessation counseling, telephone quit-line support, and/or intensive cessation support services.

We acknowledge that a limitation of this study is the small sample size. In addition, information on the number of caregivers asked to participate in our study and those who actually completed the survey was not collected. The small sample size reflects the difficulties in approaching families regarding this issue and may have led to selection bias in that caregivers who were less comfortable about discussing their smoking status, such as those who were visiting because of a child's respiratory concerns, might have been less likely to participate. This finding is not consistent throughout the literature, as it has been shown that caregivers are open to questions regarding smoking status.7 A final limitation of the study is that tobacco use was assessed through self-reporting without biochemical confirmation.

The results from our study demonstrate the need for pediatricians to play an active role in screening, counseling, and referring eligible caregivers to SCT services. Our future studies will focus on increasing SCT awareness in pediatric healthcare providers, as well as facilitating easy access by creating an onsite kiosk where caregivers have immediate access to information regarding the SCT and enrollment in smoking cessation services. It is important to consider that more than half of the caregivers in our study who smoked (54%) were not eligible for participation in SCT services, as the majority began smoking after 1988. As a result, many of our patients' caregivers who smoke do not have the benefit of the free services provided by the SCT. However, SCT-ineligible caregivers may use other smoking cessation programs because all health insurance plans offered as part of the federal Patient Protection and Affordable Care Act are required to cover tobacco cessation treatments. However, Louisiana does not require private health insurance plans to cover smoking cessation programs. As a result, patients may incur a cost depending on their plan.

CONCLUSION

The SCT has the potential to make an important contribution to reducing the illness and financial burden associated with secondhand smoke exposure among the pediatric population in Louisiana. Promotion of this program is essential, and pediatricians are in a unique position to refer caregivers who smoke to the SCT. A caregiver's visit to the pediatrician may be the ideal time for the physician to share information about the SCT and its services.

This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care, Medical Knowledge, and Practice-Based Learning and Improvement.

ACKNOWLEDGMENTS

The authors have no financial or proprietary interest in the subject matter of this article.